Citation Nr: 0004673 Decision Date: 02/23/00 Archive Date: 02/28/00 DOCKET NO. 98-10 526 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUES 1. Entitlement to service connection for mesenteric artery and left lower extremity vascular occlusion with ischemic bowel and left popliteal thrombosis as secondary to service- connected organic heart disease due to coronary atherosclerosis. 2. Entitlement to an increased evaluation for organic heart disease due to coronary atherosclerosis, currently evaluated as 60 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Alice A. Booher, Counsel INTRODUCTION The veteran has been certified as having had active service from November 1967 to October 1973, and from March 1974 to October 1982. This appeal to the Board of Veterans' Appeals (the Board) is from action taken by the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah in February 1998. The issue shown as #1 on the title page of this decision was characterized by the RO as entitlement to service connection for blood clots in the bowel and left leg. However, after reviewing the claim with regard to all of the evidence of record, the Board finds that the issue is more accurately addressed as shown as #1 on the title page. FINDINGS OF FACT 1. The veteran's mesenteric artery occlusion with ischemic bowel requiring bowel resection, and left popliteal artery thrombosis is most probably due to ischemic (atherosclerotic) peripheral vascular disease which cannot reasonably be dissociated from his service-connected organic heart disease due to coronary atherosclerosis. 2. The veteran's organic heart problems, post myocardial infarctions, are manifested by mild chest pain several times a week, and require medications; more than light manual labor is probably not feasible under old criteria but the veteran is not limited to sedentary employment and there is no sign of congestive heart failure or other more significant functional limitations. CONCLUSIONS OF LAW 1. Mesenteric artery occlusion with ischemic bowel and left popliteal artery thrombosis secondary to atherosclerotic peripheral vascular disease is proximately due to or the result of service-connected organic heart disease due to coronary atherosclerosis. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.310 (1999). 2. The criteria for an evaluation in excess of 60 percent for organic heart disease due to coronary atherosclerosis are not met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.2, 4.7, 4.104, Diagnostic Code 7005 (effective prior to January 12, 1998); 38 C.F.R. § 4.104; Diagnostic Code 7005; 62 Fed.Reg. 65207-65224 (Dec. 11, 1997) (effective January 12, 1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection for Mesenteric artery and left lower extremity vascular occlusion with ischemic bowel and left popliteal thrombosis as secondary to service-connected organic heart disease with coronary atherosclerosis. Criteria Service connection may be granted for disability which is proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995). The United States Court of Appeals for Veterans Claims (Court) has held that the term "disability" refers to impairment of earning capacity, and that such definition mandates that any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service- connected condition, shall be compensated. The Court has clearly indicated that this is not intended to limit a grant of service connection to those disabilities which were present in service or within a year thereafter, but also contemplates a chronic disability for which there is a credible medical opinion that there is a link between current disability and the in-service injury or disease. See, i.e., Caluza v. Brown, op. cit.. The Court further concluded that "satisfactory" evidence meant "credible" evidence as characterized in Caluza, supra, aff'd, 78 F.3d 604 (Fed. Cir. 1996); see also Collette v. Brown, 82 F.3d 389 (Fed. Cir. 1996). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993). The Court has also held that a determination with regard to entitlement to service connection must be made upon a review of the entire evidentiary record including thorough and comprehensive examinations that are representative of the entire clinical picture. Brown v. Brown, 5 Vet. App. 413 (1993). In this, and in other cases, only independent medical evidence may be considered to support Board findings. If the medical evidence of record is insufficient, or, in the opinion of the Board, of doubtful weight or credibility, the Board is always free to supplement the record by seeking an advisory opinion, ordering a medical examination or citing recognized medical treatises in its decisions that clearly support its ultimate conclusions. However, it is not free to substitute its own judgment for that of such an expert. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Moreover, it remains the duty of the Board as the fact finder to determine credibility of the testimony and other lay evidence. See Culver v. Derwinski, 3 Vet. App. 292, 297 (1992). Lay persons are not competent to render testimony concerning medical causation. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Service connection may be established through competent lay evidence, not medical records alone. Horowitz, op. cit. But a lay witness is not capable of offering evidence requiring medical knowledge. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The Board has the duty to assess the credibility and weight to be given the evidence. Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992) (quoting Wood v. Derwinski, 1 Vet. App. 190, 193 (1991), reconsideration denied per curiam, 1 Vet. App. 406 (1991)). The credibility and weight to be attached to these opinions are within the province of the Board as adjudicators. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When, after consideration of all the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the veteran. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1999). Factual Background Service medical records show that the veteran experienced an inferior myocardial infarction in May 1982, while on active duty. An episode during that hospitalization was initially described as ventricular fibrillation, but this was later felt to have been a reinfarction. At that time, he was diagnosed as having mild congestive failure. He was later rehospitalized at another facility for cardiac catheterization and had an episode of sharp chest pain that did not respond to Nitroglycerin. A rating of 100 percent was assigned for the veteran's service connected organic heart disease due to coronary atherosclerosis from October 15, 1982 (the day following separation from service) until January 1, 1983 at which time a 60 percent evaluation was assigned. On VA examination in 1983, the veteran repeated the above cited history and said that he had been told at the time that two coronary vessels were then completely occluded and that surgery would not be of benefit. Since then, he had taken medications including Anturane, Procardia, Propranolol and Nitroglycerin as needed, and continued being seen as an outpatient at a military facility. An electrocardiogram (ECG) showed sinus bradycardia, inferior wall myocardial infarction of unknown age, possible acute or recent, and nonspecific ST-T abnormalities. The pertinent VA diagnosis was organic heart disease due to coronary atherosclerosis with history of myocardial infarction x 2 and with angina pectoris, cardiac functional Class II. On VA hospitalization in July 1989, it was noted that the veteran had had a history of myocardial infarction complicated by ventricular fibrillation in 1982, and another infarction later that same year for which condition he continued to take Procardia, Inderal, Lopid and Aspirin. He had complaints of increasing shortness of breath, chest pain, nausea and diaphoresis, and was admitted for a determination as to whether he had had another infarction. An ECG showed similar findings to those in 1989 with the addition of ST segment flattening and T-wave changes in the lateral leads. Various changes were made to his medications. The veteran's discharge diagnosis was unstable angina. A VA examination was undertaken in 1996, although the examiner noted that the veteran had been recently under treatment, and absent those records, definitive conclusions could not be reached. Private evaluative and clinical reports as well as several private physicians' statements are in the file. In March 1996, the veteran had abdominal complaints and an endoscopy was considered. Because of his past cardiac history, however, an exercise thallium study was done. The EKG portion was unremarkable but the thallium portion showed inferior posterior wall myocardial infarction and septal and peri-infarction ischemia. He was recommended for cardiac catheterization. Further private treatment records were submitted showing that in early April 1996, the veteran had been admitted to private hospitalization for a left heart catheterization with selective coronary angiography. Angiographic findings included a normal sized left ventricle with an akinetic inferior and inferoapical wall segment and estimated ejection fraction of 51%. Coronary angiography showed the left anterior descending coronary artery had a wall irregularity with no more than a 30% stenosis. The circumflex coronary artery also had significant wall irregularity without significant occlusive disease. The right coronary artery showed a long segment of probable old dissection with recanalization in its mid portion. This gave rise to a large acute marginal branch and two RV freewall branches. The right coronary artery was totally occluded and received collateral flow from the left coronary artery system. The diagnoses were severe akinetic inferior and inferoapical wall segments with decreased left ventricular ejection fraction and severe single vessel coronary artery disease. The physician recommended that endoscopy proceed, as he needed to be treated medically but there was no significant evidence that revascularization would alleviate his symptoms at that point. Another report of the April 1996 care shows that about two months before, the veteran developed left lower extremity calf region white pain in the middle of the night. By the time he had gotten to the emergency room, there was no more pain and catheterization was not then done. However, after the later catheterization, he again became aware of white leg pain in the calf which continued to a lesser extent for several days. An ultrasound showed an occlusive wave form in the mid distal popliteal region with moderate collateral flow suggesting a clot which was felt to be possible chronic in nature. The veteran gave his consent for angiography of the left lower extremity as well as for Urokinase and possible balloon dilatation. The subsequent surgical reports are in the file showing that when a pigtail was placed in the common left iliac artery and unilateral left runoff was performed, there was clot in the trifurcation region. The catheter was moved and other procedures undertaken, and there was some mild improvement with much of the clot moving to partially occlude some of the vessels. Slow overnight infusion was undertaken. A repeat angiogram the following morning showed essential total resolution of all of the clot. The runoff showed no significant stenosis or thrombus until the terminal popliteal region. There was found near occlusive clot for a distance of about 4.5 cm., the origins of the anterior tibial, posterior tibial and peroneal vessels all contained at least small amounts of clot, but the majority of the clot was within the terminal popliteal region prior to their origins. That clot was non-occlusive but other findings suggested additional clot was possible. After 250,000 units of Urokinas there was less thrombus in similar position but after 500,000 units, there was essential occlusion of the posterior tibial and peroneal vessels with narrowing of the anterior tibial artery seen. Further overnight fusion helped with near resolution of the thrombus but irregularity in the origins of the tibial arteries were then identified as showing stenoses. There was stenosis of about 70-80% of the origin of the posterior tibia. There was an irregularity approximately 40% stenosis of the proximal 2.5 cm. of the peroneal artery with what was felt to be possible ulceration or dissection in the proximal portion. Anterior tibial vessel continued to have show flow suggesting occlusion further down . There was no dorsal pedis pulse. The initial assessment was that the procedure had been satisfactory; and that the findings were consistent with the fact that the veteran was a trucker who was required to sit for long periods of time as this thrombus was growing at the level of the stenosis rather than necessarily embolus from another source. Anticoagulation therapy was recommended, and he was to have a limited Doppler study in several weeks of the left popliteal and runoff vessels as an outpatient. It was also noted that prior to taking him off the Coumadin, a transesophageal echocardiogram should be entertained. At discharge, the veteran had a strong right dorsalis pedis pulse with near absent right posterior tibia pulse, and a strong left posterior tibial pulse with trace dorsalis pedis pulse. In April 1997, the veteran was admitted to private hospitalization with leukocytosis, abdominal pain, nausea. vomiting and a small amount of diarrhea in addition to continued chest pain and other long standing symptoms. He was placed on antibiotics and initially seemed to do better, but nonetheless he developed more severe abdominal tenderness and distention. It was initially thought that the possibility of an ischemic process was suggested and a surgical consultation was recommended. It was noted that in the situation of the arterial occlusion in his leg the year before, a source had not been found for the emboli. Private physicians evaluated him for the current abdominal problems and a laparotomy showed several feet of ischemic distal bowel which was resected. Several evaluative statements are in the file from the physicians who treated the veteran for the above complaints. It was noted that in the case of both the left leg and abdominal symptoms, he was experiencing clots for which there was no obvious cardiac source. Accordingly, it was felt that the etiologies were either an embolic event, recent versus previous showering with recent occlusion of the mesenteric artery. Initially one physician thought that it was less likely that he had atherosclerotic disease in his mesenteric arteries, but again it was felt that this would remain a moot point absent testing that could not be undertaken. As to the source of emboli in general, it was felt that an transesophageal echocardiography might resolve that question, but since he was to remain on long-term anticoagulant therapy, this would remain an academic point. The final impression given by one treating physician, dated at hospital discharge in April 1997, was "mesenteric artery occlusion with irreversible ischemia of about four and a half feet of ileum". On a hospital visit in August 1996, it was noted that the veteran had returned for a follow-up having stopped the anticoagulant therapy. He had continued heart burn and dyspepsia. Peripheral pulses showed strong right dorsalis pedis pulse with a near absent right posterior tibial pulse, and a strong left posterior pulse at the tibia but near absent pulse at the left dorsalis pedis, all of which was unchanged. The case was referred to VA physicians for an assessment stated as to whether the blood clots in his left leg and bowel were etiologically related to his heart. VA examination and assessments in November 1997 including segmental study, showed absent Dopplerable pulse of the right posterior tibial artery and dorsalis pedis artery on the left, suggesting segmental occlusive disease. An addendum was submitted in January 1998 noting that specialized tests had been conducted. It was noted that emboli were strongly considered as a basis for the mesentery artery occlusion and the vascular occlusion in the left lower extremity. However, the examiner noted that no source for the emboli had been demonstrated within the heart. Accordingly, it was felt that "the most probable explanation for the mesenteric and left lower extremity vascular occlusion is ischemic (atherosclerotic) peripheral vascular disease". Analysis Initially, the Board notes that the veteran's claim for service connection for mesenteric artery and left lower extremity vascular occlusion with ischemic bowel and left popliteal thrombosis as secondary to service-connected organic heart disease due to coronary atherosclerosis is well grounded within the meaning of 38 U.S.C.A. § 5107(a). And while certain additional specialized tests may be possible, they are not felt to be necessary, and the Board is satisfied that all relevant facts have been properly developed, and that an adequate evidentiary basis is already of record for an equitable disposition of the claim at this time. No further assistance to the veteran is required to comply with the duty to assist as mandated by 38 U.S.C.A. § 5107(a). The Board would note that it is not a question of whether the veteran's heart, for which he has service connection for a disease process relating thereto, caused his blood clots [which in turn required abdominal surgery and left leg problems, etc.] but rather whether there is a plausible basis for finding that there is a basic underlying common element which is the source for and is causing all of his atherosclerotic disability in all of its component parts. If this latter scenario can be established, the veteran is clearly entitled to secondary service connection pursuant to 38 C.F.R. § 3.310 and under the tenets of Allen, op. cit. After review of the extensive private and VA evidence in the case, including numerous expert opinions, the Board finds that there is a reasonable probability that atherosclerosis has been responsible not only for the veteran's longstanding coronary heart disease, but that unfortunately, it is now also accountable for his mesenteric and left leg problems. In fact, that appears to be the definitive conclusion of both VA and private physicians. There is simply no persuasive evidence or medical opinion of any kind to the contrary. And pursuant to Colvin and other Court holdings, VA and the Board are utterly precluded from substituting some other judgment or commentary just because it might be preferred that the opinion was something other than what was so stated. Accordingly, the Board notes that there does exist sufficient competent medical evidence of record to permit such a conclusion, namely that the veteran's atherosclerotic processes involving his peripheral system (including an ischemic bowel problem which required surgical intervention; and onsite clotting and ischemic blockage demonstrated in the circulatory system involving the left lower extremity), is virtually indistinguishable from the underlying atherosclerotic process which is and has long been the source of his service-connected organic heart disease due to coronary atherosclerosis. The evidence and credible medical opinion accordingly thereby permits a grant of entitlement to service connection on a secondary basis. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.310(a). II. Entitlement to an evaluation in excess of 60 percent for organic heart disease due to coronary atherosclerosis. General Criteria Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board has also considered all regulatory provisions which are potentially applicable through the assertions and issues raised in the evidence of record as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Conclusions reached on any given medical issue to include a determination with regard to such things as degree or extent of functional impairment of a disability, etc., the United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (hereinafter, "the Court") has repeatedly admonished that VA cannot substitute its own judgment or opinion for that of a medical expert. See, i.e., Colvin v. Derwinski, 1 Vet. App. 761 (1991). The Court has also held that a determination with regard to both entitlement to the assignment of specific ratings must be made upon a review of the entire evidentiary record including thorough and comprehensive examinations that are representative of the entire clinical picture. Brown v. Brown, 5 Vet. App. 413 (1993). The assignment of a particular diagnostic code is completely dependent upon the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in diagnostic codes by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). As will be discussed below in pertinent part, in this case, the Board has considered whether other rating codes might be more appropriate than the ones used by the RO. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). When an unlisted condition is encountered it is permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies are to be avoided, as are the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor are ratings assigned to organic diseases and injuries to be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20 (1999). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (1999). However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14 (1999). The Court has held that a claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The Court has acknowledged, however, that when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1999). Special Criteria Relatively concurrent with the pendency of this appeal, VA published new regulations for rating disability of the cardiovascular system. Under pertinent judicial holdings, the veteran is entitled to the benefit of that provision, new or old, which is to his greatest advantage. Prior to January 12, 1998 the Diagnostic Code for rating infarction(s) of the myocardium [due to thrombosis or embolism] provided that disability should be rated as arteriosclerotic heart disease. 38 C.F.R. § 4.104, Diagnostic Code 7005. Arteriosclerotic heart disease during and for 6 months following acute illness from coronary occlusion or thrombosis, with circulatory shock, etc., is rated as 100 percent disabling. After 6 months, with chronic residual findings of congestive heart failure or angina on moderate exertion or more than sedentary employment precluded a 100 percent rating is provided. Following typical history of acute coronary occlusion or thrombosis as above, or with history of substantiated repeated anginal attacks, more than light manual labor not feasible is rated as 60 percent disabling. 38 C.F.R. § 4.104, Diagnostic Code 7005 (1999). On or after January 12, 1998, Note 2 to 38 C.F.R. § 4.104 indicates that one MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 mm. per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. For rating arteriosclerotic heart disease (coronary artery disease): With documented coronary artery disease resulting in: chronic congestive heart failure, or; workload of 3 METS or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent is rated as 100 percent disabling. With more than one episode of acute congestive heart failure in the past year, or ; workload of greater than 3 METS but not greater than 5 METS results in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. When workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on ECG or X-ray, 30 percent is assignable. A 10 percent rating is assignable for lesser impairment under 38 C.F.R. § 4.104, Diagnostic Code 7005 (1999). Under the revised provisions, a myocardial infarction: during and for three months following myocardial infarction, documented by laboratory tests is rated as 100 percent disabling. Thereafter: With history of documented myocardial infarction, resulting in: Chronic congestive heart failure, or; workload of 3 METs or less result in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent is rated as 100 percent disabled. With more than one episode of acute congestive heart failure in the past year, or workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, of left ventricular dysfunction with an ejection fraction of 30 to 50 percent is rated as 60 percent disabling. When workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on ECG, echocardiogram or chest X-ray, a 30 percent rating is assignable. With workload of greater than 7 METs but not greater than 10 METS results in dyspnea, fatigue, angina, dizziness, or syncope; or continuous medication is required, 10 percent is assignable. 38 C.F.R. § 4.104, Diagnostic Code 7006 (1999). Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of regular schedular standards. 38 C.F.R. § 3.321(b)(1). Factual Background The history of the veteran's atherosclerotic heart problems is reported in the section above relating to his other disability for which the Board has herein granted service connection. On recent VA examinations in October 1998, the veteran described his current symptoms as including angina about twice a week. He had some dyspnea, fatigue and occasional dizziness. Medications included Coumadin, atenolol, liosinopril, isosorbide dinitrate, Comprazole, atorvastatin and cyanocobalamin. He reported that he was able to participate in activities of daily living such as personal hygiene, cooking, house cleaning and shopping. He was able to drive a car and take out the trash. He said he had usually worked as a long-haul truck driver, and had done that for the past 4 years, but was no longer employed. On examination in October 1998, the fee-basis examiner, WL, M.D., noted that on his submaximal graded exercise test using a Bruce protocol, he exercised 6 minutes and 44 seconds to a maximal heart rate of 127 beats per minute and maximal MET level of 8.1. Exercise was stopped at his request due to fatigue. He denied chest pain but had mild dizziness at the end of the rest. There was no ectopy or arrhythmias. Ischemia could not be evaluated since he was taking a beta- blocker. Maximal blood pressure was 132 systolic and 88 diastolic. With his poor exercise tolerance and a maximal MET level of 8.1, it was concluded that this would give him a safe estimated exercise level of 5-6 Mets. The diagnosis was organic heart disease of the atherosclerotic type which would affect his usual occupation in that he would be able to sit quietly while sitting in his truck, but that he could not tolerate unloading or loading which was a common requirement for long-haul truck drivers. There was also some concern for recurrence of an infarction while driving. The activities in which he would be affected were noted such as not doing heavy type work or over- exerting. He could do things such as lawn work with a seated mower, etc. Several statements are in the file to the effect that the veteran is unable to continue in his job as a long haul truck driver. He is currently not working. Analysis It is noted in passing that the assessment of the veteran's other, newly service-connected, atherosclerotic ramifications of the circulatory disability will, of course, be addressed when the case returns to the RO. This current evaluation is alone for the cardiac manifestations of long standing. In that regard, since the regulations have changed during the pendency of the appeal, the veteran is entitled to application of those provisions (of old and new criteria) which are to his greatest advantage. Interestingly enough, the older provisions are significantly more to his advantage, and as will be identified below, he will continue to be rated thereunder. Initially the Board finds that the veteran's claim of entitlement to an increased evaluation for his cardiovascular disease is well grounded within the meaning of 38 U.S.C.A. § 5107(a); that is, a plausible claim has been presented. Murphy v. Derwinski, 1 Vet. App. 78 (1990). In general, an allegation of increased disability is sufficient to establish a well grounded claim seeking an increased rating. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The veteran's assertions concerning the severity of his cardiovascular disease (that are within the competence of a lay party to report) are sufficient to conclude that his claim for an increased evaluation for that disability is well grounded. King v. Brown, 5 Vet. App. 19 (1993). The Board is also satisfied that all relevant facts have been properly developed to their full extent and that VA has met its duty to assist. Godwin v. Derwinski, 1 Vet. App. 419 (1991); White v. Derwinski, 1 Vet. App. 519 (1991). Of record are both ongoing evaluative reports which identify the ongoing organic heart problems. Also of record is a comprehensive and entirely adequate VA cardiovascular assessment undertaken in October 1998. The veteran takes a good number of medications which, when he is compliant, have seemingly had the effect of keeping some of his symptoms under better control. While he continues to report having angina on a twice weekly basis, there is no sign of congestive heart failure. He complains of periodic dizziness, but there is no evidence that more than light manual labor is not feasible. He has had employment over the recent past as a trucker driver, and for several reasons, he may not be able to continue in that specific job. Nonetheless, he is able to do any number of other job-related activities and is not at all limited to only sedentary activities or work. These findings, when compared to the requirements of the old criteria, are such as to which warrant a 60 percent rating and no more. Comparatively speaking, however, under the revised criteria, his measured metabolic equivalent ranges from about 4-6 or so, which along with the absence of left ventricular ejection fraction or other more significant functional incapacitations, are findings which probably most accurately are reflected in a 30 percent rating, and in any event, certainly no more than 60 percent at most. As noted above, he is entitled to those provisions which are to his best advantage. Thus, since the 60 percent rating is sustainable under the old criteria, it is unnecessary to further assess him under the revisions. It is noted that in the case of the veteran's heart disorder, there is neither contention nor evidence to sustain consideration of an evaluation under extraschedular criteria (38 C.F.R. § 3.321) as might relate to the need for frequent periods of hospitalization or extensive time off work for his heart disability other than as contemplated within schedular criteria cited above. The RO has reached such a conclusion, and the Board concurs therewith. Although the veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for an evaluation in excess of 60 percent for organic heart disease due to coronary atherosclerosis. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). ORDER Service connection for mesenteric and left lower extremity vascular occlusion with ischemic changes and emboli in the bowel and leg as secondary to service-connected organic heart disease due to coronary atherosclerosis is granted. Entitlement to an evaluation in excess of 60 percent for organic heart disease due to coronary atherosclerosis is denied. RONALD R. BOSCH Member, Board of Veterans' Appeals